Breast Reconstruction

Breast reconstruction involves recreating the breast to match the remaining natural breast as closely as possible. The main aim is to recreate the breast shape and volume, either at the same time as the mastectomy, or at a later date.

One of the first choices confronting patients is whether to undergo immediate or delayed reconstruction. Immediate reconstruction is performed during the same operation as the mastectomy. Delayed reconstruction occurs once a patient has fully recovered from a mastectomy (usually after several months).

The benefits of immediate reconstruction are:

- Better cosmetic results
- The skin of the breast can be preserved
- Smaller breast scars
- Only one anaesthetic and recovery period
- Only one stay in hospital
- No period of time without a breast

The benefits of delayed reconstruction are:

- Staggered surgery, resulting in an easier and shorter recovery following each procedure
- Time to consider whether reconstruction is right for you without delaying the cancer treatment
- Less to deal with at once

The favoured technique amongst many plastic surgeons is to use a patient’s own tissue to reconstruct the breast. In recent years, own tissue or autologous reconstructions have become more and more popular amongst patients. This tissue is usually taken from the abdomen or back, but sometimes from the buttocks or thighs. For some patients, however, an implant-based reconstruction is more appropriate.

Finally, some women still opt not to have their breasts reconstructed at all. Many women feel radically changed by their cancer experience, and some feel that a flat chest is an apt acknowledgement and expression of their post-cancer persona. Others may opt to wear a prosthetic breast rather than undergo further surgery.

Implant-based reconstruction

When a breast is reconstructed using an implant alone a silicone implant is inserted under the skin and muscle of the chest to replace the breast volume that has been removed at the time of mastectomy. This is quite a simple operation that does not involve incisions elsewhere on the body. Sometimes an adjustable implant called an expander-prosthesis can be used, this is adjusted by injections of saline which can be done in the outpatient clinic in the weeks after the operation.

In implant-based reconstruction a silicone implant is inserted behind the chest wall muscles. Sometimes an inflatable tissue expander-prosthesis is used to stretch the overlying tissues and allow adjustability after the operation.

Implant-based reconstruction is usually advised for patients who are not suitable for autologous reconstruction. This might be because they have no spare tissue to use, they are not medically fit for a larger operation, or they simply do not want a big operation involving incisions and scars elsewhere on the body. It is best for patients with relatively small breasts that do not droop at all. It can be difficult to get a natural breast shape with an implant alone so can be effective if both breasts are being removed.

The main disadvantage of implant-based breast reconstruction is that it is impossible to create a breast with a natural shape and feel. No skin is replaced so it cannot be used where there is a need for skin replacement. Most patients having an implant-based reconstruction will require adjustment of the opposite breast to improve the shape and size match. Whilst the breasts can look a reasonable match whilst dressed they will usually be different shapes when undressed. Many patients who have implant-based reconstruction will need to have further operations in the future to adjust or exchange their implant. Implants are prone to hardening, deflation, visible folds and creases, and do not give good results in patients who have radiotherapy.

Latissimus Dorsi (LD) flap reconstruction

One type of flap transfer for breast reconstruction uses the latissimus dorsi muscle from the back along with an overlying patch of skin. This muscle’s blood supply makes it extremely useful for breast reconstruction, as it gets its main blood supply from vessels emerging from the armpit. In this procedure, the muscle is transferred to the breast area by swinging it around the ribcage so that it lies at the front of the body. Using this procedure skin removed at the time of mastectomy is replaced along with some volume. Some patients will also need an implant to further augment the volume, but it is sometimes possible to remove enough fat from the back attached to the flap to replace the missing breast volume without an implant. This is called an autologous latissimus dorsi reconstruction.

In latissimus dorsi breast reconstruction a flap consisting of the latissimus dorsi muscle along with a patch of overlying skin is taken from the back and rotated around to the front in order to recreate the breast. An implant is sometimes need beneath the flap.

A latissimus dorsi flap reconstruction is a larger operation that using an implant alone, but will usually give a more natural result, particularly if an implant is not needed. It is a very durable and reliable flap. It does result in quite a large scar on the back, but this can usually be positioned to be concealed by most clothing and underwear. Losing the muscle from the back does not seem to cause any restriction of shoulder movement or strength in most patients. Latissimus dorsi flap reconstruction is most suitable for patients who do not need much skin replacement and whose abdomen is not suitable for flap transfer. It can be ideal for relatively heavily built patents who have small to medium sized breasts.

Muscle Sparing Latissimus Dorsi flap reconstruction

This is a technique which is offered by our surgeons that is similar to the LD flap but preserve most of the muscle in its original place. This reduces the problems associated with movement of the whole muscle to the front of the chest.

Abdominal flap reconstruction

The skin and fat of the lower abdomen is often the ideal tissue for breast reconstruction. A large amount of skin and volume can be replaced in order to achieve a very natural look and feel. Removal of excess skin and fat can often be a welcome bonus for the patient, resulting in a “tummy tuck”. When first described the operation involved tunnelling the lower abdominal flap with the underlying rectus abdominis muscles beneath the upper abdomen to the chest – a pedicled TRAM flap. Whilst this technique is still sometimes used most surgeons find that transferring this tissue as a free flap is more reliable. Free flap reconstruction involves the transfer of living tissue from one part of the body to another, along with the blood vessel that keeps it alive. Free flaps are entirely disconnected from their original blood supply and are reconnected using microsurgery in the recipient site. This procedure involves hooking up all the tiny blood vessels of the flap with those in the new site, and is carried out with use of a microscope, hence the name ‘microsurgery’.

In free flap breast reconstruction, skin, fat and sometimes muscle from one part of the body is transferred to the breast area. During this process, the skin and fat is completely removed from the original area and reconnected in the recipient site. Blood vessels from the armpit, or near the breastbone, are used to create a new blood supply for the transferred tissue. There are several variants of lower abdominal free flap transfer depending on which blood vessels are used and whether any muscle is transferred, these are:

Types of lower abdominal free flaps

Free TRAM flap - In this operation a small piece of muscle is taken along with the blood vessels, skin and fat
Free DIEP flap – this variant uses the same blood vessels as the TRAM flap, but they are carefully dissected out from the muscle when the flap is raised and DIEP flap contains no muscle
Free SIEA flap – In this operation some of the more superficial blood vessels on the tummy are used and no muscle is dissected or transferred

Whilst abdominal flap reconstruction can give excellent results it must be recognised that this is a major procedure. Patients spend up to a week in hospital and will undergo a recovery period lasting several weeks. There will be scars on the breast and a large scar across the abdomen as well as around the umbilicus. There may be some difficulty sitting up from lying down initially if the abdominal muscles are dissected, but in the long term most patients notice no real problems. All breast reconstruction is a process and many patients will need further procedures to adjust their reconstruction. These are usually minor procedures such as liposuction to reduce the size of the flap, scar revisions, lipofilling or nipple reconstruction. That said, autologous reconstruction is durable and once a satisfactory result is achieved it tends to be static and permanent.

What should I expect as a patient?

All breast reconstructions are done under general anaesthesia. When you come round you will have some dressings and drains. Various techniques are used to make the process as painless as possible. With free flap breast reconstruction you will have a period of careful monitoring for the first day or so after the operation, but will then be allowed to get up and about.

Once you go home from hospital you will feel very tired initially, and would be advised to have someone around to help you. After the first week you should be starting to look after yourself and begin to resume normal activities. The recovery period varies depending on which of the operations you have had done. A few weeks after the operation you will be seen again in clinic to check how you are doing and make sure all your wounds are healing well. You will then be seen a few months later to assess the outcome.

Surgical adjustments are often needed following breast reconstruction, and it may be necessary for patients to undergo one or two smaller procedures, aimed at slightly altering the shape of the breast or creating a nipple and areola.

What complications can occur?

With any operation there are some risks, steps are always taken to minimise these risks. The most frequent complication is delayed wound healing. This risk is greatest in some of the larger flap operations where the incisions are longer. If there is a wound problem it is usually minor, but more major wound healing problems can occur such as infection, skin loss, wound separation and possible reoperation. Very occasionally, soon after the surgery, bleeding may occur this may necessitate a return to theatre to stop the bleeding. Sometimes patients can collect fluid beneath the operation site, this may need to be drained off in clinic. If an implant is used there are some specific complications that can happen. In some abdominal flap surgery there is a risk of abdominal muscle weakness or perhaps even a bulge or hernia. There is a slight risk of blood clots after the operation occurring in the legs or lungs, steps will be taken before during and after the operation to minimise this risk. In flap surgery there is a risk that the circulation to the flap may cease, if this occurs it is usually in the first day or so. You will be monitored carefully to spot this, but if it occurs you will need to go back to the operating room to remedy the problem. The microsurgery may need to be redone, if so circulation will usually be restored. However there is a slight risk that it cannot and the flap is lost. The relative risk of these various complications varies between operations and the likelihood of them happening in your operation will be discussed with you. There is not much that you can do to minimise any of these risks, but in delayed reconstruction patients may be advised to try to lose weight before the operation, all patients should stop smoking prior to surgery.